Health Care Without End

SO you think it’s finished? So you think now that enrollment has hit seven million, now that the president has declared the debate over repeal “over,” now that Republican predictions of a swift Obamacare unraveling look a bit like Republican predictions of a Romney landslide, we’re going to stop arguing about health care, stop having the issue dominate the conversation, and turn at last to some other debate instead?

You think it’s over? It’s never over.

I mean, O.K., it will be over in the event of a nuclear war, or a climate apocalypse, or if the robots eventually rise up and overthrow us. (Our capacity for self-destruction is a pre-existing condition that no insurance plan will touch.)

But for the foreseeable future, the health care debate probably isn’t going to get any less intense. Instead, what we’ve watched unfold since 2009 is what we should expect for years, decades, a generation: a grinding, exhausting argument over how to pay for health care in a society that’s growing older, consuming more care, and (especially if current secularizing trends persist) becoming more and more invested in postponing death.

In the near term, this debate will go on because Obamacare has stabilized itself without fully resolving any of its internal problems. The liberal victory lap last week was half-earned: It really was a victory, given the initial website catastrophe, to arrive at seven million enrolled, and that success almost certainly establishes a new coverage baseline for any future overhaul.

But that baseline won’t be anything like universal coverage, and it may fall short of universality by a much larger margin than the law’s supporters hoped. Around a million of the seven million probably won’t make their payments, and many had insurance previously. So even with the new Medicaid enrollees and the twentysomethings added to their parents’ plans, the number of newly insured could end up around three or four or even five million short of the 13 million that the Congressional Budget Office predicted for Obamacare’s first year.

At the same time, the law’s internal structure has been rendered extremely rickety by the administration’s attempts at damage control. Nobody knows what will happen with the various suspended and hollowed-out provisions — whether the employer mandate will ever take effect, whether the individual mandate will be enforced along the lines that its architects argued was necessary for the law to work. And nobody is sure what the pool of enrollees looks like (in terms of age and average health), and what it will mean for premiums next year and beyond.

These realities make it very likely that whatever position Republicans end up taking on a potential Obamacare replacement or reform, by the next presidential election there will be increasingly vocal Democratic constituencies for change — moderates who want to be seen as doing something about rate shock, and liberals looking for a reform (ahem, single payer) that doesn’t leave 30 million Americans uninsured.

Repeal may really be a dead letter, in other words, but don’t be surprised to wake up in 2020 to endless arguments about a reform of the reform of the reform.

And don’t be surprised, either, if the debate over Obamacare is merging, by then, into the yet-more-toxic argument about how to pay for Medicare.

The Medicare debate has been postponed, to some extent, by the recent fiscal consolidation and a slowdown in health care cost inflation. But inflation should rise again as the Obamacare money sluices into the system, and even with a lower rate it would be hard to envision a future for Medicare that doesn’t involve some combination of price controls, benefit reductions and tax increases — all on a much larger scale than the numbers involved in recent debates.

What’s more, the political salience of this debate will rise for the same reason that the costs of Medicare will be rising: because the country will be older over all, and health policy inevitably matters more to the old than to the young.

Which means that the future almost certainly holds more cries of “death panels,” more ads featuring Paul Ryan clones pushing seniors over a cliff, and no doubt as-yet-undreamt-of forms of demagogy. And it means, as well, that if it’s hard to get Washington to focus on other issues now — tax reform, education, family policy, you name it — just wait awhile: It will get much worse.

It’s important to note, of course, that this “worse” will be the result of betterment: our political debates will be consumed by health care because of all that medicine can do for us, and we’ll be arguing about how to sustain what earlier generations would have regarded as a golden age.

But there’s a reason that golden ages can diminish into twilight — because the demands of the present can crowd out the needs of the future, and because what’s required to preserve and sustain is often different, in the end, from what’s required to grow.